Half of women make the decision to breastfeed before conception, whereas the remaining half may make the decision during early pregnancy.1–4 Correspondingly, early prenatal care is recognized as a critical time to initiate an open dialogue about breastfeeding. Research indicates that counseling by obstetric care providers increases the rates of breastfeeding initiation and duration.5–7 The American College of Obstetricians and Gynecologists (the College) published an opinion for the delivery of prenatal breastfeeding education by obstetrician–gynecologists, recommending that this start at the first prenatal appointment and be reinforced and expanded on in subsequent visits.8 Specific College counseling recommendations (Table 1) are similar to those supported by other maternal–child health organizations for clinicians who provide prenatal care, including the American Academy of Family Physicians, American Academy of Pediatrics, and the Academy of Breastfeeding Medicine.9–11
Despite these published recommendations, patient and obstetric provider-reported incidence of prenatal breastfeeding discussions vary widely (approximately 15–97%, respectively).12–14 Indeed, multiple studies indicate that clinicians' self-report of recommended behaviors is unreliable.15–17 In this study, we used audio-recorded first obstetric visits to describe the frequency, content, and characteristics of breastfeeding discussions between obstetric clinicians and pregnant patients.
MATERIALS AND METHODS
This analysis was part of an ongoing National Institute of Health-funded parent study about patient–provider communication in prenatal care, which included 69 health care providers and 377 patients at the time of analysis. We selected the first 172 visits for the current analysis. Details regarding outcomes of interest (eg, breastfeeding content) were not disclosed to participants. Data collection took place in an urban, hospital-based prenatal clinic serving a racially diverse population of women, the majority of whom were on medical assistance. All clinicians who provided obstetric care in the clinic were eligible for study participation. Patients being seen for their initial prenatal appointment by participating clinicians were approached for study consent and enrollment in the waiting room. After confirmation that the patient was not considering pregnancy termination or adoption, visits were audio-recorded. Recordings were begun when the patient entered the examination room before seeing the clinician and stopped when the patient exited the room to be discharged from the clinic. At the end of the visit, an investigator (C.H., J.A.T.) verbally administered a questionnaire to patient participants about their health and obstetric history, demographics, breastfeeding intentions, and recollections and preferences for breastfeeding discussions with the clinician. Audio-recorded visits were later transcribed verbatim. These transcripts as well as the original deidentified audio files and postvisit questionnaires were used in the analysis. All visits took place in a 20-month period from 2011 to 2012. The study was approved by the University of Pittsburgh Institutional Review Board, and all patients and clinicians signed written informed consent before any study procedures.
Text and audio data for all visits were reviewed for any discussion or mention of breastfeeding, total time spent discussing breastfeeding, timing of the breastfeeding discussion during the visit, initiator of the breastfeeding conversation (eg, clinician or patient), and adherence to a measurable subset of College breastfeeding recommendations, including discussion of prior breastfeeding experience, statement of support for breastfeeding, exploration of patient-perceived barriers to breastfeeding, and discussion of breast changes relative to pregnancy and breastfeeding. Audio recordings and transcripts were listened to and read in their entirety, respectively, and transcripts were additionally examined using a keyword search for the following terms: lact-, breast-, milk, feed, colostrum, nipple, formula, bottle. Patient–provider exchanges involving breastfeeding, inclusive of both speaking and pauses in conversation, were timed using a simple digital stopwatch. Researcher-observed frequency of breastfeeding discussions were compared with patient postinterview self-report of breastfeeding discussions. When any discrepancies between observed compared with reported breastfeeding discussions were noted, the audio and transcript were reviewed again.
Descriptive statistics (means, ranges, frequencies and proportions) were used to characterize the sample and frequency of breastfeeding discussions. Binary logistic regression and χ2 tests were used to assess for significant differences in breastfeeding plans among demographic groups and to examine associations among women's feeding plans, breastfeeding discussion preferences, and observed occurrence of actual discussions. Given that the number of recorded visits per health care provider varied, we used logistic regression with generalized estimating equations to control for within health care provider correlation when we examined differences in breastfeeding discussion incidence by health care provider type. Quantitative data were analyzed with SPSS 20.
We also performed qualitative analyses of the breastfeeding discussions. Conversations were coded by one of the authors (J.R.D.) for breastfeeding-specific content (eg, breastfeeding concerns), context (eg, other issues discussed during visit, clinician and patient tone), and accuracy of breastfeeding information. Thirty audio recordings (17% of sample; 21 different health care providers) were also chosen at random and independently reviewed by a second investigator (M.N.) and intercoder reliability assessed using Cohen's kappa.18 Summaries of breastfeeding discussions for each clinician were developed from the coding schema to identify patterns in the data and discussed among the study team. The final analysis represents a joint interpretation of the data among all authors. Atlas.ti 6.2 was used to organize and manage the qualitative coding.
The analysis included 172 initial prenatal visits with 47 different clinicians. Patient participants ranged in age from 18 to 45 years (mean 25, standard deviation 5.2); all were being seen for their initial prenatal appointment in the practice. Gestational dating based on patient self-report ranged from 4 to 37 weeks (mean 12 weeks, standard deviation 7.0). Number of pregnancies, including the index pregnancy, ranged from 1 to 14 (mean 3, standard deviation 2.2). Number of prior births ranged from zero to eight (Table 2).
Clinicians included six certified nurse midwives, five certified registered nurse practitioners, and 36 obstetrics and gynecology residents (postgraduate years 1–4; 15 residents had study visits over 2 postgraduate years). There were 44 female and three male clinicians. Clinician sample composition was 81% (n=38) white, 6% (n=3) black or African American, 6% (n=3) Asian, and 6% (n=3) “other” (self-report). More comprehensive clinician background data were unavailable as a result of the ongoing nature of the study and collection of most of this information in exit interviews.
In total, breastfeeding was discussed in 49 of the 172 (29%) visits (Table 1). The majority of discussions were initiated by clinicians, rather than patients, and occurred during the breast examination. The longest breastfeeding discussion lasted 3 minutes 25 seconds, whereas the mean duration was 39 seconds (mean visit duration 21 minutes). At least one College breastfeeding counseling recommendation was incorporated into 34 of the 49 breastfeeding discussions (69%). Assessment of prior breastfeeding experience was the most frequently addressed College recommendation during breastfeeding discussions (25 visits).
Breastfeeding was discussed in at least one visit by 30% of residents (n=11), 83% of certified nurse midwives (n=5), and 100% of nurse practitioners (n=5). Among health care providers who had more than one recorded visit, 22% of residents (n=8), 83% of certified nurse midwives (n=5), and 20% of nurse practitioners (n=1) discussed breastfeeding in 50% or more of all of their visits. Breastfeeding was significantly more likely to be discussed by certified nurse midwives than residents (odds ratio [OR] 24.54, 95% confidence interval [CI] 3.78–159.06, P<.01; average correlation for repeated measures among clinicians 0.185; effective n=115). Given the strong differences between certified nurse midwives and residents, we split residents into early and more senior trainees (postgraduate years 1 and 2; postgraduate years 3 and 4). No differences were noted in breastfeeding discussions between these resident groups (OR 0.58, 95% CI 0.17–2.00, P=.39). There were no other significant clinician differences in incidence of breastfeeding discussions.
Women who were married or living with a partner and those earning $15,000 or more annually were more likely than single and lower-earning women to intend to breastfeed (χ2 [2, 172]=6.7, P=0.03; χ2 [4, 163]=16.0, P<.01, respectively). Primiparous women were more likely to be unsure of feeding plans (χ2 [2, 172]=6.1, P=.04; Table 2). Older patients and patients with prior children were significantly less likely than their younger and primiparous counterparts to want to talk about breastfeeding with the health care provider (unadjusted OR 0.9, 95% CI 0.8–0.9, P=.03; unadjusted OR 0.3, 95% CI 0.1–0.5, P<.001, respectively). There were no significant patient demographic differences in whether breastfeeding was discussed in the index visit with one exception: breastfeeding was more likely to be mentioned during visits with smokers than nonsmokers (unadjusted OR 2.1, 95% CI 1.1–4.1, P=.04).
Compared with those who planned to feed artificial milk, those who intended to breastfeed and those who were undecided about breastfeeding were significantly more likely to want to talk to the clinician about breastfeeding at some point in pregnancy (unadjusted OR 9.7, 95% CI 4.2–22.5; unadjusted OR 20.4, 95% CI 6.4–65.1, respectively; P<.001). There was no significant difference in whether breastfeeding was actually discussed based on a patient's feeding plans (χ2 [2, 172]=1.56, P=.46). Those who preferred to talk about breastfeeding at the first prenatal visit (n=19; 11% of sample) were significantly more likely to actually discuss breastfeeding at the index visit compared with those who did not want to discuss breastfeeding at all (n=59; 34% of sample) or indicated that the discussion could occur at another visit (n=94; 55% of sample) (unadjusted OR 8.5, 95% CI, 2.7–27.0, P<.001; unadjusted OR 6.3, 95% CI 2.2–18.5, P=.001, respectively; Table 2).
Kappa interrater reliabilities for observed frequency of breastfeeding discussions, initiator of breastfeeding discussions, discussion of prior breastfeeding experience, and discussion of the sufficiency of a patient's anatomy for breastfeeding were calculated at 100%. Timing of discussions, clinician statement of support for breastfeeding, exploration of potential breastfeeding barriers, and discussion of breast changes related to pregnancy all achieved substantial levels of interrater agreement (kappa=0.65–0.80, P<.001). Of 25 total discrepancies between patient-reported and researcher-observed occurrence of a breastfeeding discussion (14% disagreement), 20 involved patient endorsement and researcher nonendorsement of a discussion. On rereview of audio and text, the researchers' observations were upheld in all cases.
Our qualitative examination of breastfeeding discussions indicated that most clinicians had a fairly standard repertoire that did not deviate significantly between patients. Discussions were most often initiated by health care providers in a manner that conveyed ambivalence toward the feeding decision (eg, “Do you plan on breastfeeding or bottle-feeding?,” “Did you breastfeed or bottle-feed [your other children]?”). In contrast, one clinician consistently opened the breastfeeding conversation by stating, “I hope you'll consider breastfeeding.” Thereafter, breastfeeding “scripts” typically consisted of praising the breastfeeding decision (if patient planned to breastfeed), offering a recommendation to breastfeed, and noting the benefits of breastfeeding. If patients did not raise specific questions or concerns, clinicians then transitioned to other topics.
Resident trainees rarely personally endorsed a breastfeeding recommendation; rather, they used phrases such as “[Breastfeeding is] recommended by pediatricians and OBs” and “We recommend breastfeeding.” In contrast, certified nurse midwives frequently used the first person to indicate their support for breastfeeding, eg, “I think it's worth a try,” “Any chance I can convince you [to breastfeed]?”
In discussing benefits, clinicians mentioned breastfeeding as “healthier,” “the best thing for you and the baby,” or “really good for you and the baby.” Discussions included both infant and maternal benefits (eg, accelerated postpartum weight loss; enhanced infant bonding; financial savings; fewer infant allergies and digestive problems; infants “smarter”). Comparisons of breastfeeding to formula and discussions regarding risks of artificial feeding rarely occurred. Instead, most health care practitioners maintained that breastfeeding was a “personal choice,” any breastfeeding was better than none, and combining breast- and artificial feedings was a choice equitable to exclusive breastfeeding.
Patient breastfeeding concerns broached during visits included the following: lack of time to devote to breastfeeding (eg, work or other child obligations; n=4 patients); breast appearance after weaning (n=1); adequacy of breast anatomy for breastfeeding (eg, small breasts, breast reductions; n=2); pain or discomfort with breastfeeding (n=6); compatibility of breastfeeding with certain substances or conditions (eg, alcohol, tobacco, methadone, hepatitis C; n=5); and recurrence of past breastfeeding problems (eg, latching issues, perceived low milk supply; n=3). Responses to these concerns varied among clinician type and were classified into one of three general categories: facilitative, avoidant or dismissive, and misleading. In facilitative responses, clinicians exhibited ease when breastfeeding concerns were broached and spent time validating concerns and brainstorming solutions. As a group, certified nurse midwives exhibited this style more often than either nurse practitioners or residents (eg, Certified nurse midwife: What makes you not want to breastfeed? Patient: Cause it is uncomfortable. Certified nurse midwife: Do you think? Have you heard that it hurts your breasts? Patient: Yes, I heard that… Certified nurse midwife: Sometimes it does. Especially when you’re first learning… There are a lot of good reasons to do it. It is really good for babies. Patient: What are the other reasons?). In avoidant or dismissive responses, clinicians ignored, changed the subject, or turned the conversation back to a rote list of benefits when breastfeeding concerns were introduced (eg, Patient: I tried breastfeeding, but it was like a week or two and I just went right to bottle. Resident: Okay. Patient: It was just painful. Resident: Okay. Patient: I mean, I want to try again, but it just did not work out those first two times. Resident: Your last baby was born in 2008 or 2010?). In misleading responses, clinicians perpetuated commonly held breastfeeding myths, including “pumping and dumping” as a method to clear alcohol from breast milk and the incompatibility of smoking and breastfeeding (eg, Resident: Did you breastfeed your [other] children? Patient: No, I smoke. Resident: And you are planning to bottle-feed again with this pregnancy? How can we help you to cut back on your smoking?).
Patient fears about methadone incompatibility with breastfeeding, vertical transmission of hepatitis C through breast milk, and the size of breasts negatively affecting milk output were correctly dispelled by clinicians in all cases; five of six clinicians provided a fair assessment of the minor discomfort normally associated with early breastfeeding (ie, nipple stretch pain); communication was inconsistent, however, regarding the possible negative effect of breast reduction surgery on milk supply and the key role of appropriate breastfeeding management on prevention of low milk supply and latching problems. In general, extended dialogues about these issues were rare; instead, health care practitioners tended to defer more detailed discussions to outside breastfeeding resources or until subsequent appointments.
Few recent studies have addressed the incidence and content of breastfeeding discussions during prenatal care visits, and all rely on retrospective self-report data.19–21 In one study of postpartum recall data, only 15% of mothers reported a prenatal discussion about breastfeeding duration, and only 16% reported breastfeeding counseling despite receiving care from clinicians who reported they “usually or always” discussed breastfeeding.12 In another study of postpartum women, only 17% reported that their prenatal breastfeeding concerns were addressed by the obstetric provider.22 Our study attempted to address the inconsistency between patient and health care provider self-report by examining actual incidence of discussions; our findings corroborate patient report that prenatal breastfeeding education is not routine.
Even when breastfeeding was discussed, our analysis demonstrates inadequacies in content, consistent with prior work.14,23 Graffy and Taylor24 reported that pregnant and postpartum women desired open breastfeeding conversations with clinicians, including the opportunity to ask questions. These women also expressed a need for more information before birth about normal breastfeeding and management of common breastfeeding concerns (eg, breast milk expression, timing, and duration of feedings). There is a lack of evidence, however, on preferences for and efficacy of general compared with personal endorsements of breastfeeding by health care providers. Although it may not be feasible for clinicians to engage patients in detailed breastfeeding discussions, our findings indicate that basic recommendations are not being met. At a minimum, clinicians should address the breastfeeding topics itemized in the College opinion and have resources available if questions arise beyond one's level of expertise.
This study did not address health care practitioner characteristics or opinions that may have influenced breastfeeding discussions. Evidence suggests, however, that a clinician's positive personal breastfeeding experience may improve breastfeeding counseling.25,26 Conversely, a perceived lack of time during visits, devaluation of prenatal breastfeeding discussions, inadequate breastfeeding training, or conceptualization of breastfeeding education as the pediatric provider's domain may contribute to suboptimal prenatal breastfeeding counseling.12,23,26,27 Taveras et al12 reported that among 255 mother–obstetrician dyads, 39% of mothers thought that their obstetrician's breastfeeding advice was “very important,” whereas only 8% of obstetricians thought the same. In addition, compared with midwife training programs, physician education curricula commonly lack clinical and didactic breastfeeding content,14,26 which may have contributed to the health care provider type-specific differences we observed in breastfeeding discussions (although resident trainees in the study may have not yet received planned breastfeeding education). Related to these training deficits, the U.S. Surgeon General recently issued a call for enhanced breastfeeding education for all health care providers.28
Of note, patients did not often raise breastfeeding concerns themselves, and most thought breastfeeding counseling could be deferred until later visits. However, this contradicts knowledge that infant feeding decisions most often are made before the second trimester and that clinicians are influential in these early decisions.1,4–6,12 Evidence suggests that many women are unaware of and subsequently blindsided by difficulties encountered during breastfeeding.24 Earlier breastfeeding conversations may facilitate enhanced breastfeeding preparation, confidence, and success. Breastfeeding discussions during the initial prenatal visit may be even more critical in practices serving uninsured and minority populations, because these patients are at risk for inconsistent prenatal care.29,30
Strengths of this analysis include incorporation of both qualitative and quantitative data, the relatively large sample, and use of observational rather than self-report data. However, because we analyzed first prenatal visit data from a single practice, findings may not reflect other regions, patient populations, health care systems (eg, private practices), health care practitioners (eg, attending physicians), and subsequent prenatal visits. The small number of nurse practitioners and certified nurse midwives likely limited our ability to detect significant differences among clinicians. Additionally, study participants may have censored their discussions as a result of awareness of being audio-recorded, and breastfeeding discussions may have occurred “off the record” with other clinical staff (eg, nurses). The latter may explain some of the discrepancy between patient-recollected and researcher-observed breastfeeding conversations.
Our study raises several important questions. First, it is uncertain how clinician and conversation characteristics (eg, style, content) affect actual breastfeeding outcomes. The optimal format and content of didactic and experiential breastfeeding education for clinicians also require greater attention and standardization. It is unknown whether obstetric clinicians are aware of College breastfeeding recommendations and whether they have sufficient training to implement them. Acquisition of such data are important, however, because inadequate breastfeeding support from clinicians is a highly modifiable barrier to breastfeeding initiation and continuation.
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